ST. ANTHONY COLLEGE OF ROXAS CITY, INC.

SAN ROQUE EXTENSION, ROXAS CITY, CAPIZ 5800

COLLEGE OF
NURSING AY 2021 -
2022

NCM 112: Care of Clients with Problems in Oxygenation, Fluid and

Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular
Aberrations, Acute and Chronic.

TEXTBOOK DISCUSSION

APPENDICITIS

GUEZIL JOY R. DELFIN, SN

MR. GINO PAULO A. BUIZON, RN

Clinical Instructor
Overview
Appendicitis is inflammation of the vermiform appendix.
Appendix a hollow organ located at the tip of the cecum, usually in
the right lower quadrant of the abdomen. However, it can be
located in almost any area of the abdomen, depending on if there
were any abnormal developmental issues, including midgut
malrotation, or if there are any other special conditions such as
pregnancy or prior abdominal surgeries. The appendix
develops embryonically in the fifth week. During this time, there is
a rotation of the midgut to the external umbilical cord with the
eventual return to the abdomen and rotation of the cecum. This
results in the usual retrocecal location of the appendix. It is
most often a disease of acute presentation, usually within 24 hours,
but it can also present as a more chronic condition. If there has
Diagram of the large intestine pointing to
been a perforation with a contained abscess, then the presenting the location of the appendix (Image
symptoms can be more indolent. The exact function of the retrieved from
https://www.flickr.com/photos/ajc1/2368725
appendix has been a debated topic. Today it is accepted that this 786)
organ may have an immunoprotective function and acts as a
lymphoid organ, especially in the younger person. Other theories contend that the appendix
acts as a storage vessel for "good" colonic bacteria. Still, others argue that it is a mere
developmental remnant and has no real function.

Types of Appendicitis
Acute Appendicitis - It develops very fast within a few days to hours, and requires prompt
medical treatment or surgery.

Chronic Appendicitis- The symptoms may be milder and may come and go over several weeks,
months, or even years. It is a rare condition.

Simple Appendicitis - Cases with no complications.

Complex Appendicitis - Cases that involve complications like appendix rupture or abscess.

Causes of Appendicitis
Appendicitis can have more than one cause. In many cases, the cause is not clear. Possible
causes include
Common Causes
1. Fecal impaction and/or a fecalith

 A layered buildup of calcium salts and fecal debris around a piece of fecal material
within the appendix

2. Lymphoid Hyperplasia

 The appendix contains lymphoid (immune system) tissue that can become inflamed as a
result of infection or inflammatory bowel disease (IBD)

3. Parasites

 Examples: Schistosomes species, pinworms, Strongyloides stercoralis

Uncommon Causes
1. Tumor
2. Foreign Material

 A wide variety of foreign objects can become lodged in the appendix. Some of these
include: shotgun pellets, intrauterine devices, tongue studs, and activated charcoal

Signs and Symptoms

 Progressively worsening pain

 Painful coughing or sneezing
 Nausea
 Vomiting
 Diarrhea
 Inability to pass gas (break wind)
 Fever
 Constipation
 Loss of appetite

Risk Factors
Modifiable Risk Factors

 Low fibre diet - Increases the viscosity of feces, which can cause fecal matter to get lodged
in the appendix
Modifiable Risk Factors

 Age- Appendicitis most often affects people between the ages of 15 and 30 years old.
 Sex- Appendicitis is more common in males than females
 Family History- People who have a family history of appendicitis are at heightened risk of
developing it.

Pathophysiology

Appendicitis is an inflammation of the appendix, a small organ attached to the cecum of the
large intestine. This inflammation is caused by an obstruction of the appendiceal lumen (the
internal cavity of the appendix). Because the appendix is constantly secreting mucus from its
mucosa to keep the tissue moist and prevent pathogens from entering the bloodstream, a
blockage results in increased intraluminal pressure. An increase in intraluminal pressure can
decrease blood flow to the appendix, leading to tissue hypoxia. This causes an ulceration of the
appendix lining, which can become infected and results in the inflammation and edema
associated with appendicitis.
Clinical Manifestations
Patient presented to the Emergency room with a four-hour history of right lower quadrant
(RLQ) abdominal pain. The pain originated in the umbilical region, radiating diffusely across the
lower abdomen and subsequently localised to the RLQ. The pain was of sudden onset, sharp
and colicky with progressing intensity. The patient has a fever and crying for almost an hour.

General appearance: Patient is female, entered to the hospital accompanied by her mother.
Patient appears thin, weak, bloated abdomen, pale skin, crying and irritable.

Signs Noticed
(+) abdominal pain localized to the RLQ
(+) sharp and colicky pain
(+) fever
(+) abdominal bloating
(+)Pain becomes more severe over time

Accompanying symptoms

(+) Painful to move when walking, coughing, and

sneezing

(+) Localized tenderness & muscle guarding

(+) Loss of appetite

Assessment
Physical assessments - Abdomen Assessment:

Rebound Tenderness
is performed when the patient reports abdominal pain or
tenderness is felt when palpating the patient’s abdomen.  To
perform this test; choose a site away from the painful area,
hold your hand at a 90 degree angle and push down slowly
and deeply into the abdomen. Then lift quickly; a normal
response results in no pain upon release of the hand. If pain
is felt when the hand is lifted it confirms rebound tenderness
which is used as a reliable sign for peritoneal inflammation
which often accompanies appendicitis. For further
confirmation of appendicitis, other tests such as a CT scan
should be performed.
Iliopsoas Muscle Test
This test is performed when there is acute abdominal
pain and there is suspected appendicitis. With the
patient lying supine, the right leg is lifted straight up,
flexing at the hip. The examiner places their hand on the
lower part of the right thigh. They will then push the leg
down as the patient attempts to resist and hold their leg
up. A negative test results if no pain occurs when this
test is being performed. A positive test result occurs
when pain is felt in the right lower quadrant of the
abdomen as this test is performed, determining that there is either an inflamed iliopsoas
muscle or a perforated appendix.

Diagnostic/Laboratory Tests
1. CBC count: White blood cell (WBC) count values range from 10,000 to 16,000cells/mm3
when patient suffers from appendicitis.  As well there is a decrease
in approximately 75% of a patient’s Neutrophil count.  Normal neutrophil levels range
between 1,500 to 8,000 cells/mm3.

2. C-reactive protein (CRP): Is an acute phase reactant that is synthesized by the liver in
response to infection or inflammation. It's values rapidly increase within the first 12
hours and then shortly after it will normalize once symptoms of appendicitis
appear. CRP levels greater than 1 mg/dL are found in appendicitis. The use of this
method alone to diagnose appendicitis is not advised as CRP lacks specificity and does
not distinguish between sites of infection.  

3. Other possible diagnostic lab tests include: Liver and pancreatic function test (to rule out
possible damage to other organs); urinalysis (to rule out a possible UTI); urinary beta-hCG
(to rule out possible early ectopic pregnancy in women)

Unfortunately there is no outright test that can be performed to diagnose appendicitis.

Although with the combination of physical assessments, lab testing diagnostic imaging cases
of appendicitis can be hypothesized to exist.

Diagnostic Procedures - Imaging:

Abdominal Computer Tomography (CT) scan: Uses
radiographic imaging with or without a contrast medium in
order to detect the size of the appendix. The test is primarily
performed to determine if the appendix is enlarged. This
scan is generally used to diagnose patient with atypical
presentations of appendicitis as the imaging is able to have a high rate of sensitivity and
specificity for confirmation of a diagnosis.

Ultrasonography:  Uses ultrasound (high frequency sound) in

order to view internal body structures. This is the preferred
method to view internal organs, as there is no exposure to
radiation (as there is with a CT scan). A healthy appendix is
not viewed when an ultrasound is performed. With
appendicitis an enlarged area of the appendix is viewed as a
non-compressible tubular structure that ranges between 7-
9mm in diameter. At this point a diagnosis of appendicitis can
be confirmed

Medical Surgical Management

The standard treatment for appendicitis is an
appendectomy (surgical removal of the
appendix). This may be done through a
laparoscopic appendectomy, open
appendectomy, or through emerging
technology routes like a natural orifice
transluminal endoscopic surgery. Prior to
surgery, individuals with appendicitis will
receive broad-spectrum antibiotics to reduce
the risk of wound infection.

Appendectomy

 Surgical removal of the appendix (standard treatment for appendicitis).

 Potential complications from appendectomy include wound infection, intraabdominal
abscess, and intraabdominal adhesion.
 For patients with complicated acute appendicitis with peritonitis or abscess,
combination of antibiotic therapy and fluid therapy could be used for 6 to 8 hours prior
to appendectomy to prevent sepsis and dehydration.

Types of appendectomy: 

 Laparoscopic appendectomy.
 Open appendectomy.
  New emerging technologies: single incision laparoscopic appendectomy and natural
orifice transluminal endoscopic surgery (NOTES).

Current research suggests that antibiotic treatment alone can be used

to manage uncomplicated appendicitis. However, individuals need to
understand that they are at risk of recurrence and will likely need
appendectomy.

Laparoscopic Appendectomy: three small incisions at the umbilicus,

left lower quadrant, and lower midline of abdomen. At these incision
sites, camera and surgical instruments are inserted to remove the
appendix.  
Open Appendectomy: single incision at the right lower quadrant of
abdomen (traditional surgical procedure). 

 Common prophylactic antibiotics

Most commonly used antibiotics are cephalosporin and imidazole

derivatives for surgical prophylaxis
Nursing Care Management
Preoperative Management

 Keep patients on NPO (withhold from oral foods and fluids).

 Establish IV access to prevent dehydration and administer parenteral analgesic as
ordered.
 Monitor for changes in level of pain.
 Monitor for signs of ruptured appendix and peritonitis
 Administer parenteral prophylactic antibiotic as ordered.
 Position right-side lying or low to semi fowler position to promote comfort.
 Start at least 60 minutes prior to appendectomy
 Significantly reduces wound infection
 Avoid the application of heat in the abdomen.
 Use antibiotics with broad coverage of gram-negative and anaerobic bacteria
 Avoid laxatives or enema.

Postoperative Management

 Monitor temperature for signs of infection.

 Assess incision for signs of infection such as redness, swelling and pain.
 Maintain NPO status until bowel function has returned.
 Administer analgesic and antiemetic if needed for pain and vomiting as ordered.
 Encourage early ambulation.
 Administer postoperative antibiotics as prescribed.
 Not recommended as a routine use
 Only recommended for complicated perforated appendicitis: postoperative intravenous
antibiotics for 3 to 5 days. Antibiotic treatment will be stopped when core temperature
is <38°C for 24 hours, patient tolerates two meals consecutively, mobilize
independently, and WBC (white blood cell) count normalizes.   

Nursing interventions to prevent infection

 Administer prophylactic antibiotics as prescribed during preoperative care to reduce

infection.
 Monitor for signs of infection: abdominal tenderness, fever, and increased abdominal
pain. 
 Avoid applying heat and palpating abdomen to prevent rupture or
wound dehiscence, reducing further complication
Nursing interventions for postoperative pain

 Encourage patient to rest flat on bed then in semi-fowler’s position to reduce surgical
pain.
 Encourage walking on the first postoperative day to stimulate peristalsis. Once patient
passes flatus, abdominal discomfort will be reduced.
 Administer analgesic as prescribed to relieve pain.
 Place ice bag to desensitize the nerve endings on abdomen and relieve pain (Do not
apply heat).
 Encourage deep breathing exercises. Inhale in the nose and exhale to the mouth for 5 to
10 seconds.